client intake form

First name

Last name

Phone

Is there anything about your physical or emotional well-being, current health, injuries, medications, or other circumstances you feel would be important for me to know before we work together? *Share only what you feel comfortable sharing.

How did you hear about us?

Friends/Family

Social Media

Google Search

Other

What brings you here, and what would you most like support with right now? *Share only what you feel comfortable sharing.

What would you like to feel, experience, or be different as a result of our work together? *There’s no right answer-just share what comes to mind.

Are there any areas of your life where you’re currently feeling stuck, overwhelmed, disconnected, or wanting change? *This might include relationships, work, stress, confidence, your body, intimacy, or anything else that feels important to you.

Is there anything you would like me to be especially mindful of while supporting you-such as boundaries, triggers, sensitivities, accessibility needs, or practices you prefer not to do? *You are always welcome to pause, modify, or decline any practice.

Are you currently experiencing any pain, tension, discomfort, numbness, or other physical sensations, you would like me to know about? If so, please tell me where in your body and, if possible, rate the intensity from 1-10.

Have you ever experienced any significant injuries, illnesses, surgeries, accidents, or other physical events that you feel may be relevant to our work together? *Share only what feels relevant and comfortable. Approximate dates can be helpful.

What types of stress are you currently experiencing in your life, if any? *This might include work, relationships, family, finances, health, major life changes, or anything else that feels stressful right now.

Are there any emotions or emotional patterns that have been coming up for you regularly? * For example, worry, sadness, anger, frustration, fear, grief, loneliness, or feeling overwhelmed. Share only what feels comfortable.

How have your sleep, energy, and daily routines been feeling lately? *You might include anything you’ve noticed about sleep, energy levels, movement, appetite, or your ability to rest and recharge.

Have you experienced any significant life, events, losses, or difficult experiences that you feel may be relevant to our work together? * You do not need to share details you are not comfortable sharing. A brief answer is completely ok.

What helps you feel grounded, calm, connected, or more like yourself? * This could be movement, music, time outside, breathing, meditation, being alone, being with certain people, creativity, or anything else that feels supportive.

Is there anything that helps you feel especially safe, comfortable, and supported when working with a practitioner? * This might include communication style, pacing, having choices, extra explanation, quiet, movement, or anything else that helps you.

Is there anything else you’d like me to know about you before our session? * Anything that feels important, helpful, or simply something you’d like me to know is welcome here.

I understand that somatic practices, breathwork, meditation, yoga, and other services offered through Hedonè Soma are intended to support personal growth, body awareness, relaxation, and overall well-being. These services are educational and supportive in nature and are not a substitute for medical care, psychotherapy, diagnosis, or treatment by a licensed healthcare professional.

I understand that participation is voluntary, and that I am always in control of my experience. I may pause, modify, or decline any practice at any time. I agree to communicate my needs, boundaries, and comfort level, and to inform my practitioner of any relevant health, concerns, injuries, medications, or changes that could affect my participation.

By signing below, I acknowledge that I have read and understood the information above and consent to participate in services provided by Hedonè Soma

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